The direct extension
of a subphrenic abscess into the pericardial cavity is a rare finding.
We report a 13 year old boy with Past History of Abdominal surgeries
presenting with Right Upper quadrant pain, fever, chest pain and
shortness of breath. An abdominal USG diagnosed a subphrenic abscess and
an ECG demonstrated diffuse ST and T wave changes depictive of Acute
Pericarditis. Echo guided drainage of thick pus from the pericardial
cavity was performed which followed USG guided drainage of subphrenic
abscess and finally Exploratory Laparotomy and drainage of subphrenic
abscess + Mediastonotmy and Pericardiostomy + diaphragmatic repair was
performed.

Key words:
Subphrenic abscess, pericardial cavity

INTRODUCTION

Subphrenic abscesses are
known to follow abdominal surgeries. The manifestations of a subphrenic
abscess range from a severe acute illness to an insidious chronic process
characterized by intermittent fever, weight loss, anemia, and nonspecific
symptoms. The known complications of subphrenic abscess are
lower lobe lung collapse or development of a
pleural effusion. We report a rare complication in which subphrenic
abscess ruptured into pericardial cavity.

CASE REPORT

A 13 year old boy
presented in Mayo Hospital with the Complaint of intermittent pyrexia (more
at night), associated with chills and rigors and pain Right Hypochondrium
for 5 days. Patient had a history of 2 previous abdominal surgeries. First
one was performed for Blunt trauma abdomen 1.5 yrs ago in Allied Hospital
Faisalabad. Patient most likely had a intestinal perforation for which
Exploratory Laparotomy was done. After few days Patient started having
abdominal pain and fever for which another Exploratory Laparotomy was done
in Pindi Bhatiyan. (Details of procedure were to be reproduced by the
patient.). At the time of admission his vital were Pulse 90/min, Blood
Pressure 120/70mm of Hg Temp 99.6F Respiratory Rate 20/min. Regarding
General Physical Examination pallor was + ve and jaundice –ve Abdominal
Examination revealed fullness in the right Hypochondrium with moderate to
severe tenderness. Provisional diagnosis of subphrenic abscess was made
which was confirmed on abdominal USG which showed a 13 x 14cm size subphrenic abscess. The
plan was to explore the patient On the 2nd day of admission patient
complained of chest pain which was central in origin and associated with
moderate respiratory distress. The findings were thought to be due to the
abscess pushing on the diaphragm and causing dyspnoea and discomfort. 24hrs
later patient got severly dyspneic and orthopneic; He could only count upto
6 in a single breath. His vitals were Pulse. 110 Blood Pressure. 100/60
Temp 99F Respiratory Rate 38 /min. JVP was normal. ECG showed ST
segment elevation in I, II, AVF and all the chest leads. A diagnosis of
pericarditis was made and supportive treatment instituted with
corticosteroids and antibiotics. Next day an urgent Echocardiography
revealed pericardial collection and a pig-tail catheter was inserted into
pericardial cavity to actively aspirate 500 ml of thick yellow brown pus. An
USG guided aspiration of subphrenic abscess was also performed and 1500 ml
thick chocolate coloured puss was aspirated. Post Intervention vitals were P
100. BP 110/60. Temp 98.6 RR 30. This followed rapid improvement in the
overall condition of the patient. On 2nd post intervention day the pt was
releaved of his dyspnoea and orthopnea and could count upto 18 in a single
breath. His culture report showed growth of “pseudomonas and E Coli”.

5 days later his
exploration was planned. Exploratory Laparotomy revealed 1 liter creamy pus
in Right subphrenic space and a hole in the diaphragm communicating with the
pericardial cavity through which pus oozed out with every heart beat.
Mediastonotomy and pericardiostomy performed and pus drained, pericardial
cavity washed with normal saline and gentacin instilled and a corrugated
drain was placed over there.

Fig:
Subphrenic abscess draining to pericardial abscess.

DISCUSSION

Subphrenic abscess are
localized infections between the colon and the diaphragm on the left side of
the abdomen and the liver and the diaphragm on the right side of the
abdomen. They may occur from rupture of any organ in the abdomen or
following abdominal surgeries. Rupture of a subhphrenic abscess into
pericardial cavity is a rare but serious complication. The objective of
reporting this case is to highlight this rare but dreadful complication of
subphrenic abscess.

The pathophysiological
mechanism of this complication is unknown1. Pleural effusion is
recognized to occur from subphrenic abscess either on right or left side2.
These pleural exudates may be caused by changes in the capillary
permeability or lymph flow in the diaphragm induced by local effects of
inflammatory products2345. We hypothesize a similar mechanism for
the pericardial change, plus these inflammatory productsmight
have resulted in breaching the diaphragm and made a hole in the pericardiumas was seen in this case. The proximity of subphrenic inflammatory
process to the pericardium overlying the left diaphragm may be a very key
factor in determining whether pericardial complication develops1.With
relatively little liver mass adherent to the left subphrenic surface,
abscess there have exposure to area over which pericardium lies6.

There are many
complications of abscess including sepsis, pyrexia of unknown origin,
abdominal pain, hiccups and chest pain but subphrenic abscess complicating
pericarditis is a very rare condition shown by the very little research work
done on it. This indirect pericardial complication of subphrenic abscess is
serious, posing life threatening risk and requiring costly and invasive
procedure for management. In patient with subphrenic abscess early
recognition of pericarditis may be life saving. Evidence of pericarditis
should be aggressively sought by bedside examination, ECG, echocardiography,
USG or CT scan. Conversely, subphrenic abscess should be sought when
pleuropercardial exudates are otherwise unexplained1.